Elderly Health Journal 2017; 3(1): 28-34.

Shahid Sadoughi University of Medical Sciences, Yazd, Iran

Journal Website : http://ehj.ssu.ac.ir

Original Article
Lived Experiences of Elderly Patients with Coronary Artery Disease: A
Hermeneutic Phenomenological Study

Majideh Heravi-Karimooi1, Nahid Rejeh1, Mohammad Abbasi2*

1.
Elderly Care Research Center, School of Nursing and Midwifery, Shahed University, Tehran, Iran
2.
Department of Nursing, School of Nursing and Midwifery, Qom University of Medical Sciences, Qom, Iran

ABSTRACT

Article history
Received 5 March 2017 Introduction: Coronary artery disease is the most common type of cardiovascular disease.
Accepted 13 May 2017 Despite the increasing number of patients with coronary artery disease, the lived
experiences of these patients have remained unknown. The purpose of the study was to
understand the lived experiences of elderly patients with coronary artery disease.

Methods: This qualitative research was conducted using an interpretive phenomenological

approach. Participants included thirteen elderly patients (9 males and 4 females) with
coronary artery disease selective of purposive sampling method from Coronary Care Unit of
Shahid Beheshti Hospital in Qom, 2016. Data were collected through semi-structured
interviews between 55 - 80 minutes. The interviews were recorded and transcribed. The
Van Manen's proposed six steps was used to analyze the data.
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Results: The main theme of study was "living with ups and downs". It included sub-themes
of 1) losing calmness,2) trying to achieve calmness through spirituality, 3) losing health, 4)
trying to promote health through modification of lifestyle, 5) perceiving family support, 6)
living in fear, 7) living with a damaged heart".

Conclusion: Findings of the research indicated that the coronary artery disease led patients
to experience ups and downs for the participations. After the disease, they were trying to
achieve calmness through some strategies. Members of the treatment team, especially
nurses should provide self-care education for to make them be have successfully in this
field.

Keywords: Experience, Coronary Artery Disease, Qualitative Study

Citation: Heravi-Karimooi M, Rejeh N, Abbasi M. Lived experiences of elderly patients with coronary artery disease:
a hermeneutic phenomenological study. Elderly Health Journal. 2017; 3(1): 28-34.

Introduction

Cardiovascular diseases are the most prevalent report several experiences after the onset of disease as
serious disease and the most problem of health which well as different signs and symptoms of angina (5, 6).
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threatens human life in the world (1). These diseases
are the most common causes of death in the developed
and developing countries and the numbers of suffering
people from them are increasing (2). Based on the
available reports, cardiovascular diseases are
subjective to the most common cause of death in Iran
(3). Coronary artery disease is the most common type
of the cardiovascular disease which has made the
following coronary artery atherosclerosis (1, 4).
Suffering from the coronary artery disease causes
notable changes in all aspects of patients' lives. They
Elderly people experience fear, feeling of insecurity,
as well as lack of confidence in the present and future
after myocardial infarction (7).
Fear of death during sleep and fear of pain during
walking have affected various aspects of their lives (3,
8, 9). Through a review on researches conducted in
Iran, it was concluded that less quantitative researches
have been conducted in Iran about experience of
living with coronary artery disease. Furthermore, the
conducted studies evaluated a few aspects of living

*
Corresponding Author: Department of Nursing, School of Nursing and Midwifery, Qom University of Medical Sciences, Qom,
Iran. Tel: +982537835588, Email address: mohamad_abbasi55@yahoo.com
 Heravi-Karimooi et al.

with coronary artery diseases mostly rate of outbreak
and risk factors for cardiovascular diseases (10).
Despite previous study in Iran (11) these
experiences have not yet been examined deeply and
enough cognition is not available in this field.
Therefore, it seems necessary to conduct a qualitative
research to explain experiences of elderly patients
with coronary artery disease deeply.
Cognition of these patients' experiences leads to
creation of a unique knowledge in this field and
provides some information for members of the
treatment team especially nurses about training,
caring, and consulting this type of patients. The
purpose of the study was to explore the lived
experiences of elderly patients with coronary artery
disease.
Methods
The qualitative study was performed using a
hermeneutic phenomenological approach, a most
commonly method for understanding meaning of lived
experience. Van Manen believed that knowledge and
understanding come through analyzing the reflective
descriptions of people with relevant experience.Van
Manen's proposed six steps were used to conduct this
study (12). In Van Manen’s opinion hermeneutic
phenomenology, a combination of description and
interpretation, expresses that description and
interpretation are not separated from each other. It
should be noted that Van Manen's six steps are as a
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The first step: Turning to the nature of lived
experience
Van Manen expresses that the first step in studying
a phenomenon is the researcher’s interest in nature of
that research. The researcher’s attention was drawn to
the phenomenon of the lived experiences of elderly
patients with coronary artery disease since he was
working in CCU of a hospital in Tehran.
The second step: Investigating experience as we live it
Patients who referred to Shahid Beheshti Hospital
in Qom city, Iran in 2016, underwent a purposive
selection of participants with maximum variation
sampling; nine men and four women. The inclusion
criteria were willingness to participate in the
research,talk about their lived experiences and age 65
years or older; and people with severe spiritual-
psychological problems and physical diseases were
excluded. Demographic characteristics of the study
participants are shown in Table 1.
Deep semi-structured face to face interviews were
carried out individually to collect data conducted in 55
to 80 minutes sessions in coronary care unit and heart
unit of Shahid Beheshti Hospital of Qom. Interviews
started with a general question about cardiovascular
disease. The researcher let the participants to say their
real experiences about coronary artery disease through
his silence. In the case of needing more perception
and explanation, the researcher used follow-up
questions such as “would you please explain more

guidance to conduct the research and there is no
obligation to observe the order in the steps. Each
activity is explained in the following.
about the issue” or “what was your purpose about the
part which you said”. Interviews were continued until
data saturation was achieved, in the study after eleven
interviews, the interviews ended when no new data
was resulted.

Table 1. Demographic characteristics of the study participants

Participant Number Marital status Occupation Age Sex Time after
status disease (y)
1 Married Retired 66 Male 1
2 Married Farmer 71 Male 5
3 Married Housekeeper 62 Female 6
4 Married Self-employed 64 Male 9
5 Married Housekeeper 71 Female 8
6 Married Housekeeper 65 Female 7
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7 Married Retired 69 Male 6

8 Married Self-employed 66 Male 4
9 Married Housekeeper 61 Female 3
10 Married Self-employed 65 Male 6
11 Married Self-employed 72 Male 7
12 Married Farmer 71 Male 2
13 Married Retired 73 Male 4

Elderly Health Journal 2017; 3(1): 28-34. 29

 Lived Experiences of Elderly Patients with CAD
The third step: Reflecting on essential themes
Thinking in inherent themes was descriptor of the
considered phenomenon. Researcher determined the
main themes for the phenomenon of elderly patients'
experiences with coronary artery disease through
thematic analysis. Van Mannen has proposed three
approaches for thematic analysis including holistic
approach, selective approach, and detailed approach.
It should be noted that holistic and selective
approaches were applied in this study. In the process
of data analysis, after converting audio files to texts,
texts were studied several times accurately and
general perception from participants' experiences was
obtained through holistic approach, then researcher
wrote some paragraphs and studied them several times
accurately) 12). He selected those sentences and
phrases that described experiences of elderly patients
with coronary artery disease and extracted them as
semantic units. This semantic units were then written
in a separate paper. and placed in a separate category
according to their semantic similarity, in order to
obtain more general and abstract phrases.
The fourth step: Hermeneutic phenomenological
writing
Van Mannen's approach is the art of writing and
rewriting. In this stage the purpose was achieving a
strong description of the phenomenon of elderly
patients' experiences with coronary artery disease.
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The fifth step: Maintaining a strong and oriented
nursing relation to the Phenomenon
This stage is for maintenance of a strong and
directional communication with the considered
phenomenon. In this stage, in order to avoid getting
away from the purpose of study, the researcher
considered the main research question to maintain the
strong and directional communication with the
phenomenon.
The sixth step: Balancing the research context by
considering parts and whole
Van Mannen is making a balance in the field of
linking whole and detail. He worked on this stage by
continues review of whole and detail through holistic
and selective approaches and according to the main
research question.
According to Lincoln and Guba, the authors
verified the accuracy of the data with the four criteria
of validity, reliability, credibility, and transferability.
An effective communication was made with the
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participants based on trust to guarantee the validity of
study (12). In order to increase the reliability of the
data and create a deeper understanding of the
phenomenon, the authors used prolonged exposure to
the subject and obtained data, reviewing the data and
matching them with the experiences of the
participants and the observers’ comments. To confirm
the data, texts of the interviews were given to patients
after analysis. Also, the research process was
evaluated step by step through participation of the
research team as well as other experts.
30
Ethical considerations
This article is resulted from the approved project of
Shahed University with ethical code of
IR.Shahed.REC 1395.108. The researchers received
the allowance to conduct the study from the related
authorities by introducing themself to Shahid Beheshti
Hospital in Qom city. Then, they selected the
participants and received verbal informed consent
from them. The researchers committed to keep their
personal information, interviews, and anonymity
confidential.
Results
The research was conducted in order to perceive,
identify, and interpret the lived experiences of elderly
patients with coronary artery disease. Findings of the
research indicated that the main theme of lived
experiences of elderly patients with coronary artery
disease was “living with ups and downs” including
sub-themes of 1) losing calmness 2), trying to achieve
calmness through spirituality, 3) losing health, 4)
trying to promote health through modification of
lifestyle, 5) perceiving family support, 6) living in
fear, and 7) living with a damaged heart.
1. Losing Calmness
Most of the participants expressed that they had lost
their calmness after disclosure of their cardiovascular
disease and also hospital discharge. In their
expression, they had suffered from worry, and
anxiety, thought seriously about importance of heart
in life and the fact that if the heart has problem, their
lives might be in danger. They had lost their calmness
by reviewing their heart task and further probabilities
such as cardiac arrest and myocardial infarction.
About this issue a participant said : "man's life
depends on heart; if a problem is made, the whole life
is endangered, one of our neighborhoods had heart
problem for years, the poor man had no relaxation, I
am really not calm now”. Another participant said:
“Those early days when I was told that I have a heart
problem and should be hospitalized, I didn’t believe it
at all. I didn’t have any problem. I was confused and
believed that my life was ruined”.
2. Trying to Achieve Calmness through Spirituality
Following to become aware about the critical situation
after the diagnosis of cardiovascular disease and
discharge from hospital, the participants had
concluded that they should keep calm to continue life.
They utilized many strategies to keep calm. Many of
them had resorted to spirituality and tendency to
religious practices to keep calm.
About this issue a patient said: “After it became clear
that I have heart disease I was trying to have night
prayer, I woke up and spoke to God for one or two
hours. I was calming myself down with this plan.
Through this I was keeping my morale high. I could
remove my anxious by reading Quran and saying
prayer”.
Elderly Health Journal 2017; 3(1): 28-34.
 Heravi-Karimooi et al.
About this issue another patient said: “After I was
discharged, I told O Lord! You created us, our deaths
and lives are in your hands, ”I just put my trust in
God.
A patient said about his prayers after heart disease:
“I was only thinking of God, I prayed, I had confided
myself to God and thanked God”.
3. Losing Health
Many of participants said they have not paid much
attention to their health status before diagnosis of the
disease and before appearance of the signs and
symptoms of cardiovascular diseases. They had never
thought that they might have cardiovascular problems.
Having had disclosure of the disease, they felt that
they had lost their health and each moment were
waiting for its aftermath. The patients mentioned the
importance of heart and considered its health as health
of the body. One of the patients said: “with this heart
disease I know I have lost my health, each moment my
heart may become more clogged and have worse
status. If man’s heart is clogged he will suffer from
lesion”.
In many participants' opinion, heart is the most
sensitive organ of a body and needs high care and
attention, but many of them didn’t pay attention to the
issue before suffering from heart disease at all.
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Another patient said: “Before suffering from the
disease I didn’t know about sensitivity and
vulnerability of heart a lot, if I had suitable food diets
and exercised, maybe I did not suffer from heart
disease now and I was healthy and peppy”.
4. Trying to Promote Health through Lifestyle
Modification
After concluding that they need to promote their
health, participants had used several strategies. They
decided to modify their lifestyles to promote their
health and hearts.
About this issue, one of the patients said: “man
should do something before a problem happens, now
that I have this situation I should try hard to maintain
my health”.
Some participants mentioned instances on lifestyle
modification: following suitable food and drug diets,
regular referring to hospital in order to control
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cardiovascular status, managing stress, modifying
work hours, regular and planned exercising, walking,
and positive thinking.
A patient said about his decision to have further
activity after diagnosis of heart disease: “I was very
busy and I also wasn’t aware a lot, I did not know
about the importance of the issue. For example, you
should exercise an hour a week, control nutrients, and
avoid cooking foods with high saturated oils. I used to
Elderly Health Journal 2017; 3(1): 28-34.
go mountains once a week for one or two hours ,but
this was not enough for a person who is sitting all the
time, should deal with customers, becomes angry
regularly, and needs to work hard”
Another patient said: “After diagnosis of the disease, I
decided to have activity and do exercise, I shouldn’t
sit in a place like old men, the situation was difficult”
Another participant mentioned his daily exercises and
said: “After my heart disease, I exercised every day I
woke up at 5a.m., went to park and exercised.”
Another patient emphasized the necessity to take care
of heart and said: “After the disease, heart needs care
and the suitable care is to avoid consuming salt, fat,
and sweets according to physicians' orders. Doctors
gave us an instruction which we should observe, such
as not eating salt, fat, and red meet. I observed these
cases”.
5. Perceiving Family Support
Participants mentioned that they perceived family
support more than before. They considered that family
support from the patient is important and emphasized
that this patient's life depends on support of family. In
this regard a participant said: “family support from a
patient with heart disease is very important. If the
family doesn't support the patient, he/ she become
effete and will die”.
A participant mentioned the effect of support from
a patient with heart disease and said: “After the
disease my family supported me a lot. If there is no
support, the patient will suffer a worse disease. When
I see my family is sympathetic, supportive, as well as
cooperative and I have some facilities, I become
motivated”.
6. Living in Fear
For patients living with coronary artery disease was
always accompanied with fear, anxiety, uncertainty,
fear of the future, and feelings of hopelessness so that
all participants after suffering from cardiovascular
diseases expressed such experiences. They were
always afraid of heart attack, cardiac arrest, and
sudden death. Being worry and having fear were so
severe in some patients that they were worry about
heart attack even in sleep. They were afraid of cardiac
arrest during nights; feeling worry and fear caused
disturbance in their sleeps.
In this regard, a patient said: "After heart disease I
had much concern, I was too sad. Sometimes I slept
and said I will die tomorrow morning and will not
wake up”.
About living after heart disease a patient
mentioned: "living with heart disease is with anxiety
and worry; being worry about cardiac arrest and
31
 Lived Experiences of Elderly Patients with CAD
death”
“My life after heart disease has always been
accompanied with anxiety, I’m thinking if I sleep in
night I will have rupture of heart tomorrow morning.
I’m always worried, I’m always sad” said a patient
about his living after heart disease.
Another participant talked about feeling of being
hopeless after suffering from heart disease: “After
heart disease I was always assuming two modes for
myself and the situation was a new experience for me.
I was in a situation which my hope to continue living
was very low”.
A patient expressed his uncertainty about his heart:
"after the disease my heart is not working correctly,
there is no confidence to that. When a heart becomes
ill, you should take care of yourself a lot, you need to
limit yourself.”
7. Living with a Damaged Heart
Some participants said their hearts have been
damaged after suffering from coronary artery disease
and should live with damaged hearts for the rest of
their lives. They mentioned some symptoms such as
chest pain, shortness of breath, edema, palpitations,
and cough.
A participant talked in this regard: "After the
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disease my heart was damaged; now I’m living with a
damaged heart.”
Another participant said about his heart status after
the disease: "If a human’s heart is damaged what is
left for him/her to live further? I didn’t care about
myself and damaged my heart.”
Discussion
Findings of the research showed that the lived
experiences of elderly patients with coronary artery
disease were with “ups and downs” with sub-themes
of “losing the calmness, trying to achieve calmness
through spirituality, losing health, trying to promote
health through modification of lifestyle, perceiving
family support, living in fear and living with a
damaged heart”. Living with coronary artery disease
was with ups and downs for participants of the study.
They were frequently comparing living with coronary
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artery disease to their normal status. Suffering from
the disease had divested patients from calmness and
confidence; they were expressing some concerns
about future by imagining probability of having heart
problems in future such as heart attack and cardiac
arrest was with fear and stress. Many studies had
mentioned heart disease as a stressful and anxious
event (5). Symptoms of cardiovascular diseases are
with anxiety, depression, and fear of physical
disability; this factor causes losing calmness of the
person by sudden and unexpected start.
32
Participants were using many strategies to keep
calm and return to the normal situation. They utilized
the strategy of spirituality, tendency to religious
actions, and paid more attention to spiritual issues to
keep and promote calm. Positive effect of suffering
from coronary artery disease in elderly participants
was the fact that they utilized several strategies.
Considering the cultural and religious grounds of
patients and also their religions, i.e., all of them were
Shia, they all used spirituality and religion to keep
calm and achieve calmness. Spirituality and tendency
to spirituality are also experienced in patients with
cancer, cardiovascular diseases, and chronic disease
(3-17). Momen Nasab et al., mentioned “trust in
God” in their research on patients' experiences. Also,
they added that heart attack makes spiritual dimension
of participants more prominent and spirituality
performs an important role to deal with such stressful
and dangerous events of heart disease. They had
expressed that spirituality had a significant effect on
their recovery process fromthe starting moments of
the disease towards recovery process (5).
All patients mentioned roles of their religious
beliefs in bearing hardships and problems after
coronary artery disease. Many researches have shown
that patients use their religious beliefs in encountering
problems and difficulties. Spiritual beliefs are to feel
dependency on a divine and powerful force which
causes life satisfaction and reduction of depression in
patients (18, 19).
Participants were adapted to their problems by
remembering power of God in all affairs oflife and by
resorting to Quran and Imams. They were always
mentioning the holy verse of “Remembrance of God
certainly brings comfort to all hearts” “Verily hearts
become calm with rememberance of God”. Using
spirituality in addition to compatibility with problems
had effects on recovery process. In many studies the
relation of spirituality, physical and psycholoigical-
spiritual health,as well ascompatibility with disease
has been mentioned (5, 14, 17).
After experiencing coronary artery
disease,patientsconcluded that they have lost their
health and had totry to achieve it. All their efforts
were in order to reach health again and even promote
itthroughsome startegies. They had decided to modify
their lives to poromote their health. They were
utilizing some startegis such as managing stress,
regular exercising, modifying working hours, and
changingfood diet. After a heart event, patients had no
other wayto modify lifestyle.
Afrasiabi far et al., wrote: "elderly people had used
some approaches to reduce consequences of the
disease and return to previous life after heart attack
despite tensions and limitations. They believed
returning to normal life requires maintenance of
abilities despite the existing limitations. For this
purpose, patients had considered self-reliance and
self-care as their strategies (20).
Patients said after suffering from coronary artery
disease, they had well been supported by family. They
were aware of the critical role or family support and
thought that continuing their lives with the disease
Elderly Health Journal 2017; 3(1): 28-34.
 Heravi-Karimooi et al.
mostly depends on family support. Some experts
described family support as the level of having
affection, companionship, care, respect, attention, and
received help by other people, groups, friends, and
others. Patients also mentioned that they received
affection, companionship, support, and
encouragements from their families.
Attention of family to patient is one of the most
essential kind of care, according to Iranian culture,
since families have deep relationships with members.
Many reports are available about effects of families
'supports on patients. Supporting patients prevents
from the outbreak of physiological effects of disease,
increases self-care, and has a positive effect on
physical and social statuses of patients. Also, family
support increases patient's performance (5, 21,22).
For patients, living with coronary artery disease
was always accompanied by fear, anxiety, worry so
that all participants had experienced fear after
disclosure of the disease. They were always afraid of
heart attack, cardiac arrest, and sudden death. The
prevalence of worry and fear of heart attack were so
high in some patients that they felt them even in sleep.
The negative feelings of anxiety and fear caused
disturbance of their sleeps. Afrasiabi Far et al.,
expressed experience of patients’ lives after heart
attack as “in shadow of fear". Theme of life in shadow
of fear had sub-classes of death fear by having another
heart attack, fear of physical disability, and fear of
becoming dependent to others. Fear of cardiac arrest
and sudden death is one of psychological responses of
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elderly patients with heart attack which they
experience from beginning of symptoms (20, 23).
Experience of fear included fear of death during sleep
and fear of pain during going out from house (3, 24).
Participantsmentioned importance of heart in lifetime.
They mentioned heart as the “king of body”. This
feeling that heart is damged now made them to be
always worry. Theysuffered from fear, worry, and
feeling that they should face death very soon due to
damaged heart. In a research,“seeing death” and “the
verge of death” were reported asheart disease themes
(3, 25).
Patients had feelings of hopelessness about future
of their lives following feelings of damaged heart and
mental involvement. This experience was challenging
for them and made them worry that their physical
statuses may become worse every moment. Feelings
of hopelessness had affected all aspects of their
lives(8). Fear of disability to do the routine actionsand
dependency to others were most prevalent fears of
most patients.
[ DOR: 20.1001.1.24236179.2017.3.1.5.2 ]
Conclusion
Findings of the research indicated lived experiences
of elderly patients with coronary artery disease. The
coronary artery disease had made them to lose their
calmness. They were trying to achieve calmness by
tending to spirituality and doing religious activities.
Aware of coronary artery disease, patients imagined
that they have lost their health and via modifying
lifestyle, they were trying to promote their health.
Elderly Health Journal 2017; 3(1): 28-34.
They were supported by family along with their claim
of high positive effects of family members on heart
disease. Their lives was with fear, anxiety, worry, and
feeling of hopeless. They imagined that their hearts
are damaged and should continue their lives with
damaged heart. All findings of this study emphasized
on necessity of training patients and their family
members. Also, findings of the research can be used
in care, training, and managing fields. Therefore,
professors and trainers of nursing, nurses working in
clinic and society, nursing mangers, patients 'planners
and families can use findings of the research to
promote patients 'training, consulting, quality of care
and support from patients more and more.
It is suggested to conduct a study in the field of
strategies of achieving calmness and effects of
religious consultations on promoting calmness and
giving confidence to patients’ lives suffering from
coronary artery disease.
Study limitations
Some limitations of qualitative studies are small
sample size and the inability to generalize the results.
The forgetfulness of some elderly participants about
their experiences can be considered as another
limitation of this research.
Conflict of interest
None.
Acknowledgment
This article is resulted from the approved projects
of Shahed University IR. Shahed. REC 1395.108.
Hereby, the financial support of the university and
participants' cooperation in the study are appreciated.
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